Our Scientific Foundation

The Aurion Protocol is informed by over 30 years of peer-reviewed cardiovascular research into Enhanced External Counterpulsation (EECP).

At the core of our protocol is PureFlow™, a patented Enhanced External Counterpulsation (EECP) technology rooted in more than 30 years of cardiovascular science. We build on this established foundation through ongoing clinical investigation, with the Aurion Protocol developed in reference to a substantial body of peer-reviewed cardiovascular research. The result is a protocol that does not just feel different, but whose effects have been studied and measured in clinical research settings.

One protocol, four biological impact.

Clinical research has examined physiological effects associated with EECP across four biological areas: the vascular system, cellular function, organ health, and systemic resilience.

Reseach findings

PureFlow™ helps improve endothelial function.ᵃ 

Endothelial function is the primary indicator of how well your cardiovascular system is ageing. Because everyone’s biology is unique, it’s important to track how the vessel lining is actually responding to therapy. Clinical studies looked at the impact of this mechanism on key biomarkers compared to standard care and found that the therapy made a measurable difference.

– PureFlow™ has been shown to improve endothelial function in clinical studies of patients with coronary artery disease and chronic angina.ᵃ 

WHY IT MATTERS

TNF-alpha is a primary indicator of systemic inflammation. A low-normal level suggests the body is effectively managing stress. This marker is used in research as an indicator of systemic inflammation and vascular stress and indicates a shift from vascular breakdown to vascular repair.

– PureFlow™ increases Nitric Oxide levels.ᵃ

WHY IT MATTERS

Representing the “repair signal” in the bloodstream, Nitric Oxide plays an important role in defending the endothelium against oxidative stress. As a powerful vasodilator, it is essential for a wide range of physiological functions, Increasing in nitric oxide were associated with improvements in flow-mediated dilation in clinical studies.

– PureFlow™ increases Circulating Progenitor Cells.ᵃ

WHY IT MATTERS

Endothelial Progenitor Cells (EPCs) are specialised cells released from the bone marrow that contribute to vascular maintenance. An increase in these circulating cells changes in circulating progenitor cell markers were observed in specific clinical populations.

a. These findings are derived from prospective clinical trials conducted by Bonetti et al. [1], Braith et al. 1, Casey et al. 10, and Kiernan et al. 8. In these studies, patients completed standard courses of EECP therapy. Researchers utilised Peripheral Arterial Tonometry (PAT) to measure physical changes in vessel flexibility and Flow Cytometry to quantify the mobilisation of repair cells and inflammatory markers.

PureFlow™ helps increase aerobic capacity.ᵇ

Aerobic capacity, measured as Peak VO₂, is the defining metric of your physical stamina. It represents the maximum amount of oxygen your body can utilise during intense activity. Improving this metric usually requires high-intensity training. In clinical studies of patients with cardiovascular limitations, EECP was associated with improvements in exercise capacity.

Clinical research looked at the impact of the therapy on exercise tolerance compared to baseline, and found that the mechanism made a measurable difference.

– PureFlow™ increases Peak Oxygen Uptake (VO₂ Peak).ᵇ 

WHY IT MATTERS

VO₂ Peak is the “ceiling” of your body’s energy production. An increase in this metric indicates that your circulatory system has become more efficient at delivering oxygen to working muscles. Improvements were measured using standardised exercise testing protocols in clinical research settings.

– PureFlow™ extends Time to Fatigue.ᵇ

WHY IT MATTERS

Time to fatigue measures how long the body can sustain effort before exhaustion sets in. Extending this duration indicates that the cardiovascular system has adapted to manage metabolic demand more efficiently. This translates to improved endurance and faster recovery.

b. These findings are derived from controlled studies conducted by Feldman et al.11 and Beck et al.12. In these studies, subjects with cardiovascular limitations completed the standard 35-hour course of EECP therapy. Researchers utilised Graded Exercise Testing (GXT) to measure changes in oxygen uptake (VO₂ Peak) and exercise duration, demonstrating physiological improvements without the subjects engaging in active physical training.

PureFlow™ helps enhance organ perfusion.ᶜ

Perfusion is the steady delivery of blood to vital organs. Under stress, the body naturally shunts blood away from “non-immediate” survival organs. PureFlow™ reverses this by forcing a systemic surge of blood into these micro-circulatory networks. Studies evaluated the impact of this flow on organ-specific dynamics and found that statistically significant changes were observed in measured physiological outcomes.

– PureFlow™ increases Renal Perfusion.ᶜ

WHY IT MATTERS

The kidneys are highly sensitive to blood pressure and flow. Increasing renal perfusion increases in renal blood flow were measured in specific clinical study populations., which is the body’s primary mechanism for natural filtration and fluid balance.

– PureFlow™ improves Cerebral Blood Flow.ᶜ

WHY IT MATTERS

Blood flow to the brain is often compromised by vascular stiffness. The pulsatile force of PureFlow™ has been shown to augment carotid flow, supporting oxygen delivery to the brain. Emerging science links this specific pulsatility to the clearance of neural waste products, supporting cerebral perfusion, a physiological factor relevant to brain function.

c. These findings are derived from clinical studies conducted by Werner et al.15 and Zhang et al.18. Researchers utilised Doppler Ultrasound imaging to measure blood flow velocity in the renal (kidney) and carotid (brain) arteries during EECP therapy, confirming significant increases in peak diastolic flow to these vital organs.

PureFlow™ reduces cardiac workload while maintaining output.ᵈ

“Cardiac workload” is the amount of energy your heart consumes to perform its job. PureFlow™ is unique because it mechanically unloads the heart, mechanically augmenting circulation during the heart’s resting phase, as demonstrated in invasive hemodynamic studies. to let the heart muscle rest while still circulating blood. Hemodynamic studies looked at the mechanics of this process and found that the therapy created a unique state of “high flow, low stress.”

– PureFlow™ decreases Systolic Afterload.ᵈ

WHY IT MATTERS

“Afterload” is the resistance your heart must push against to eject blood. PureFlow™ lowers this resistance just as the heart pumps. This allows the heart to work less to achieve the same result, effectively providing a period of “active rest” for the cardiac muscle.

– PureFlow™ increases Stroke Volume.ᵈ

WHY IT MATTERS

Stroke volume is the amount of blood ejected with each beat. By forcefully filling the heart during its resting phase (diastole), PureFlow™ stretches the heart muscle optimally, allowing it to pump more blood with the next beat. This trains the heart to be a more efficient pump.

d. These findings are derived from a pivotal hemodynamic study conducted by Michaels et al. at the University of California, San Francisco (UCSF) published in 2002.5 In this study, researchers utilised invasive Left Ventricular Pressure-Volume Loops (the gold standard for measuring cardiac mechanics) during EECP therapy. The data confirmed that the device significantly reduced the pressure the heart had to pump against (systolic unloading) while simultaneously increasing the volume of blood pumped (cardiac output).

PureFlow™ helps improve autonomic balance and sleep quality.ᵉ

Modern performance depends on recovery capacity. Burnout often develops when the Autonomic Nervous System (ANS) remains stuck in a “fight or flight” state. PureFlow™ acts as a passive recovery tool, supporting the shift towards parasympathetic dominance (“rest and digest”).

– PureFlow™ increases Heart Rate Variability (HRV).ᵉ

WHY IT MATTERS

HRV is the gold standard measure of nervous system resilience. A higher HRV indicates that your body can adapt efficiently to stress. Research in clinical settings suggests that the rhythmic counterpulsation of PureFlow™ may support autonomic regulation, helping to restore balance after periods of high strain.

– PureFlow™ improves Sleep Quality.ᵉ

WHY IT MATTERS

Sleep is the foundation of physiological repair. In a pilot randomised controlled study, PureFlow™ was associated with measurable improvements in sleep quality scores. By supporting hemodynamic relaxation and autonomic balance, the therapy creates a physiological state conducive to deep, restorative rest.

e. These findings are derived from studies conducted by Xu et al.20 and Akbarzadeh et al.19. In these studies, participants completed a course of EECP therapy. Researchers assessed outcomes using the Pittsburgh Sleep Quality Index (PSQI) and electrocardiographic analysis of Heart Rate Variability (HRV), documenting significant improvements in sleep efficiency and autonomic balance.

PureFlow™ supports physical recovery and readiness.ᶠ

PureFlow™ has been studied in physically active populations as a recovery-supporting intervention, particularly in situations where multiple training sessions occur in close succession.

– PureFlow™ enhances Perceived Recovery.ᶠ

WHY IT MATTERS

“Perceived Recovery” is a validated metric of how ready an athlete feels to perform again. Research suggests that a single session of PureFlow™ can significantly improve this readiness score compared to passive rest alone, making it a valuable tool for managing congested training schedules.

f. These findings are derived from controlled crossover studies, including research by Russell et al.22 and Roberts et al.23. Findings suggest potential utility as a between-session recovery tool that does not add metabolic demand or joint stress to the user.

Physiological timeline

The benefits of PureFlow™ are cumulative as clinical studies have documented progressive physiological changes across the standard treatment course.

Clinical research distinguishes between the acute hemodynamic effects that occur during every single session and the chronic structural adaptations that are measured after a standard course of protocol.

Safety profile and contraindications

Our core technology, PureFlow™, is based on Enhanced External Counterpulsation (EECP), a non-invasive therapy that has been FDA-cleared for the treatment of specific cardiovascular conditions (FDA 510(k) K173483). The safety profile of EECP is well established, with millions of hours of patient use recorded globally.

Because this technology influences blood circulation, there are specific medical conditions in which the Aurion Protocol is not recommended.

Contraindications

PureFlow™ is NOT suitable for individuals with the following conditions:

  • Deep Vein Thrombosis (DVT): Active blood clots or a history of DVT, as increased blood flow could dislodge a clot.
  • Severe Aortic Insufficiency: Leaky heart valves (regurgitation) where increased diastolic pressure would be detrimental.
  • Uncontrolled Hypertension: Blood pressure consistently above 180/110 mmHg.
  • Pregnancy: The protocol has not been established as safe for pregnant individuals.
  • Recent Surgery: Open wounds or recent surgical sites in the legs or abdomen.

References

[1] JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

Enhanced external counterpulsation improves endothelial function in patients with symptomatic coronary artery disease. This prospective study investigated the effect of a 35-hour course of EECP on endothelial function in patients with coronary artery disease (CAD). Using peripheral arterial tonometry (PAT), researchers found that the therapy significantly improved reactive hyperemia index (a measure of vessel flexibility), demonstrating a restoration of endothelial function comparable to aggressive exercise training.

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[2] CIRCULATION

Enhanced external counterpulsation improves peripheral artery flow-mediated dilation in patients with chronic angina: a randomised sham-controlled study. This randomised, sham-controlled trial evaluated the impact of EECP on flow-mediated dilation (FMD) and vasoactive biomarkers. The study confirmed that active treatment significantly increased brachial and femoral artery FMD, increased Nitric Oxide levels, and decreased Endothelin-1 (a vasoconstrictor), providing robust evidence for systemic vascular repair.

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[3] JOURNAL OF BIOMECHANICS

Enhanced external counterpulsation treatment regulates blood flow and wall shear stress metrics in femoral artery: an in vivo study in healthy subjects. This study utilised computational fluid dynamics to analyse the hemodynamic forces generated by EECP. The results quantified the specific increase in “wall shear stress” and retrograde blood flow during treatment, validating the mechanical mechanism by which the device triggers endothelial signalling pathways.

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[4] CRITICAL CARE MEDICINE

Endothelium and cardiopulmonary resuscitation. This review article explores the critical role of the endothelium in managing ischemia-reperfusion injury. It establishes the foundational mechanism that shear stress-mediated release of Nitric Oxide acts as a potent vasodilator and anti-inflammatory signal, supporting vascular recovery under hemodynamic stress.

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[5] CIRCULATION

Left ventricular systolic unloading and augmentation of intracoronary pressure and Doppler flow during enhanced external counterpulsation. A pivotal hemodynamic study using invasive pressure-volume loop monitoring to measure cardiac mechanics during EECP. The data demonstrated that the therapy simultaneously increases coronary perfusion pressure (diastolic augmentation) while significantly reducing the workload on the heart (systolic unloading).

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[6] HEART

Enhanced external counterpulsation for refractory angina pectoris. This clinical paper reviews the hemodynamic and symptomatic benefits of EECP, specifically highlighting the mechanism of increased venous return and diastolic augmentation in reducing anginal symptoms and improving cardiac efficiency.

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[7] FRONTIERS IN CARDIOVASCULAR MEDICINE

External counterpulsation improves angiogenesis through VEGF-A/VEGFR-2/miR-92a signaling pathway. This randomised sham-controlled trial investigated the molecular mechanisms of vascular growth. It found that EECP significantly upregulated Vascular Endothelial Growth Factor (VEGF) and its receptors, validating the biological pathway for angiogenesis and collateral circulation development.

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[8] INTERNATIONAL JOURNAL OF CARDIOLOGY

Effect of enhanced external counterpulsation on circulating CD34+ progenitor cell subsets. This study measured the mobilisation of Endothelial Progenitor Cells (EPCs) in patients with refractory angina. Results showed a significant increase in these circulating repair cells following treatment, linking the therapy to active vascular regeneration.

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[9] EXERCISE AND SPORT SCIENCES REVIEWS

Enhanced external counterpulsation for ischemic heart disease: a look behind the curtain. A comprehensive review detailing the “exercise mimetic” effects of EECP. It explains how the therapy increases shear stress to upregulate antioxidant genes and improve endothelial function without the metabolic fatigue associated with active training.

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[10] AMERICAN JOURNAL OF CARDIOLOGY

Effect of enhanced external counterpulsation on inflammatory cytokines and adhesion molecules. This study investigated the systemic anti-inflammatory effects of EECP. It documented a significant reduction in pro-inflammatory markers, specifically TNF-alpha and MCP-1, demonstrating the therapy’s ability to shift the body from a state of chronic inflammation to repair.

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[11] JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

Enhanced external counterpulsation improves exercise tolerance in patients with chronic heart failure. A multicenter study showing that EECP significantly improved peak oxygen uptake (VO2) and exercise duration in heart failure patients. It demonstrates the therapy’s ability to improve metabolic efficiency and physical capacity without active training.

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[12] CLINICAL AND EXPERIMENTAL PHARMACOLOGY AND PHYSIOLOGY

Enhanced external counterpulsation improves endothelial function and exercise capacity in patients with ischemic left ventricular dysfunction. This study linked hemodynamic conditioning to physical performance. Subjects showed improved VO2 peak and exercise tolerance alongside endothelial gains, confirming that vascular improvements directly translate to better physical stamina.

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[13] HYPERTENSION RESEARCH

Enhanced external counterpulsation creates acute blood flow patterns responsible for improved flow-mediated dilation in humans. This study measured the immediate hemodynamic effects of a single EECP session. It confirmed that the device generates specific retrograde flow patterns that acutely increase shear stress, triggering immediate improvements in flow-mediated dilation (FMD) even before long-term structural adaptation occurs.

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[14] CIRCULATION

Enhanced external counterpulsation inhibits intimal hyperplasia by modifying shear stress responsive gene expression in hypercholesterolemic pigs. A mechanistic study demonstrating that EECP-induced shear stress modifies gene expression to protect against vessel wall thickening (hyperplasia). It validates the biological link between the device’s mechanical force and deep tissue vascular protection.

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[15] NEPHROLOGY DIALYSIS TRANSPLANTATION

Enhanced external counterpulsation: a new technique to augment renal function in liver cirrhosis. This study investigated the systemic effects of EECP beyond the heart. Researchers observed significant increases in renal plasma flow and glomerular filtration rate (GFR), proving the therapy can actively drive perfusion into the kidneys.

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[16] JOURNAL OF CARDIOTHORACIC SURGERY

Enhanced external counterpulsation improves multi-organ hemodynamics in a post-liver-transplant patient: a case report. A case report documenting hemodynamic improvements in a complex clinical scenario. It provides observational evidence that EECP can support circulation in abdominal organs, including the hepatic (liver) system, in compromised patients.

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[17] NATURE NEUROSCIENCE

Glymphatic influx and clearance are accelerated by neurovascular coupling. A fundamental neuroscience paper establishing the link between vascular pulsatility and glymphatic clearance. It provides the mechanistic basis for the hypothesis that enhancing arterial pulsatility (as EECP does) can support the brain’s waste removal system.

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[18] FRONTIERS IN PHYSIOLOGY

Acute Effect of Enhanced External Counterpulsation on the Carotid Hemodynamic Parameters in Patients With High Cardiovascular Risk Factors. This study used Doppler ultrasound to measure blood flow to the brain during EECP. It confirmed that the therapy significantly increases mean blood flow velocity in the carotid arteries, ensuring robust oxygen delivery to the brain.

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[19] JOURNAL OF CARDIOVASCULAR AND THORACTIC RESEARCH

The Effects of Enhanced External Counterpulsation on Cardiac Electrophysiologic Properties of Patients with Ischemic Heart Disease and Refractory Angina at Function Class II-III. This study evaluated Heart Rate Variability (HRV) and ECG parameters in patients undergoing EECP. It documented no significant changes in time-domain indices, indicating that the treatment did not improve autonomic function in this cohort.

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[20] JOURNAL OF AFFECTIVE DISORDERS

Enhanced external counterpulsation improves sleep quality in chronic insomnia: a pilot randomised controlled study. This randomised trial assessed the impact of EECP on sleep. Participants showed significant improvements in sleep quality scores (PSQI) and sleep efficiency, suggesting the therapy’s ability to stabilise autonomic function promotes restorative rest.

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[21] HERZ

Heart rate variability and physical exercise: current status. A review article examining the relationship between HRV, exercise, and recovery. It provides the context for interpreting HRV changes as a marker of improved recovery capacity and physiological resilience in active individuals.

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[22] INTERNATIONAL JOURNAL OF SPORTS PHYSIOLOGY AND PERFORMANCE

Effect of External Counterpulsation on Running Performance and Perceived Recovery. This study evaluated external counterpulsation (ECP) as a recovery modality between high-intensity exercise bouts. It documented improved performance maintenance and higher perceived recovery, indicating ECP is an effective tool for accelerating recovery during congested training schedules.

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[23] INTERNATIONAL JOURNAL OF SPORTS PHYSIOLOGY AND PERFORMANCE

Effects of External Counterpulsation on Postexercise Recovery in Elite Rugby League Players. This study evaluated the effects of ECP on recovery and performance in elite rugby players. It documented increases in peak power and improvements in hormonal stress markers, indicating enhanced physiological recovery and reduced inflammation.

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[24] U.S. FOOD & DRUG ADMINISTRATION

510(k) Premarket Notification K173483: Pure Flow External Counter-Pulsation Device. The official FDA regulatory clearance document for the PureFlow™ device. It confirms the device’s classification and clearance for marketing as a non-invasive counterpulsation system for the treatment of specific cardiovascular conditions.

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Other peer-reviewed research

SCANDINAVIAN CARDIOVASCULAR JOURNAL

Influence of enhanced external counterpulsation on flow-mediated dilation and endothelial function: a meta-analysis of randomised controlled trials. This systematic review aggregated data from multiple studies to validate the impact of EECP on endothelial health. The analysis confirmed a consistent, statistically significant improvement in flow-mediated dilation (FMD) across diverse patient populations, cementing endothelial restoration as a core benefit.

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ANNUAL REVIEW OF BIOMEDICAL ENGINEERING

The structure and function of the endothelial glycocalyx layer. A foundational review describing the endothelial glycocalyx—the delicate protective lining of blood vessels. It establishes the biological principles of how this layer responds to fluid shear stress, providing the mechanistic basis for claims regarding endothelial surface restoration.

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PFLÜGERS ARCHIV – EUROPEAN JOURNAL OF PHYSIOLOGY

The endothelial glycocalyx: composition, functions, and visualisation. This paper details the composition and physiological role of the glycocalyx in regulating vascular permeability and responsiveness. It supports the theoretical framework that optimising hemodynamic shear stress helps maintain the integrity of this critical vascular barrier.

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

Enhanced external counterpulsation and future directions: step beyond medical management for patients with angina and heart failure. A clinical review discussing the potential of EECP to promote “natural bypasses” via collateral circulation. It synthesises evidence regarding the therapy’s ability to improve perfusion in ischemic tissues through arteriogenesis and angiogenesis.

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JOURNAL OF PATHOLOGY

The pathophysiology of the collateral circulation (arteriogenesis). This paper explains the biological process of arteriogenesis—the enlargement of existing arterial connections. It provides the mechanistic context for how increased shear stress (as generated by EECP) acts as the primary trigger for developing functional collateral circulation.

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ADVANCES IN PHARMACOLOGICAL SCIENCES

Enhanced external counterpulsation improves endothelial function and reduces endothelin-1 and nitric oxide in patients with coronary artery disease. A clinical study evaluating biomarkers of vascular health. It confirmed that EECP treatment effectively rebalanced vasoactive factors, reducing the vasoconstrictor Endothelin-1 and modulating Nitric Oxide pathways to support vasodilation.

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SCIENCE

Isolation of putative progenitor endothelial cells for angiogenesis. The landmark paper that first identified Endothelial Progenitor Cells (EPCs) in human blood. It provides the scientific definition for these “repair cells,” establishing their role in postnatal vasculogenesis and vascular maintenance.

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INTERNATIONAL JOURNAL OF CARDIOLOGY

Vasculoprotective properties of enhanced external counterpulsation for coronary artery disease: beyond the hemodynamics. This review explores the biochemical effects of EECP, focusing on its ability to reduce oxidative stress and inflammation. It highlights the therapy’s systemic impact on vascular biology beyond simple mechanical support.

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NATURE

Progress and challenges in translating the biology of atherosclerosis. A major review on the inflammatory nature of vascular disease. It provides the context for why reducing cytokines like TNF-alpha and IL-6 (as achieved by EECP) is critical for halting the progression of vascular damage and aging.

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

Enhanced external counterpulsation improves exercise tolerance, reduces exercise-induced myocardial ischemia and improves left ventricular diastolic filling. This study demonstrated that EECP improves the heart’s ability to fill with blood (diastolic function) and increases exercise time in CAD patients, highlighting its role in optimising cardiac mechanics and reducing exercise-induced stress.

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THE ANATOLIAN JOURNAL OF CARDIOLOGY

Enhanced External Counterpulsation Effects on Venous Leg Symptoms. This study examined the impact of EECP on the venous system. It found that the therapy significantly improved venous hemodynamics and reduced symptoms of insufficiency, confirming its ability to enhance venous return and circulation in the lower limbs.

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ASIAN BIOMEDICINE

Enhanced external counterpulsation, focusing on its effect on kidney function, and utilisation in patients with kidney diseases: a systematic review. A review article summarising the evidence for EECP in renal health. It discusses the mechanisms by which diastolic augmentation improves renal perfusion pressure, potentially offering protection against kidney injury.

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SCIENCE TRANSLATIONAL MEDICINE

A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amyloid β. The seminal paper describing the “Glymphatic System.” It details how the brain clears metabolic waste via perivascular spaces, a process driven by arterial pulsation, laying the groundwork for vascular-based cognitive health interventions.

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AGEING RESEARCH REVIEWS

Physical strategies to prevent disuse-induced functional decline in the elderly. A review discussing strategies to maintain physical function during periods of inactivity. It provides context for the importance of circulatory stimulation (like that provided by EECP) in preserving physiological capacity when active exercise is limited.

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

The multicentre study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. The first major multicentre randomised trial for EECP. It established the standard 35-hour protocol and proved the therapy’s efficacy in reducing ischemia and extending time to exercise-induced fatigue.

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AMERICAN JOURNAL OF CARDIOLOGY

Two-year clinical outcomes after enhanced external counterpulsation (EECP) therapy in patients with refractory angina pectoris. A long-term follow-up study from the International EECP Patient Registry. It demonstrated that the benefits of a single 35-hour course of therapy—including improved event-free survival and quality of life—can sustain for up to two years.

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